From The Appeals Desk Episodes

Physicians’ jobs today are very hard. There are so many demands on their time, and there is not enough time in the day to do everything they need to do. So it is understandable that a busy clinician would ask “Who Cares?” When it comes to Clinical Documentation Improvement, or CDI. In reality, Doctors need to care about this stuff. In this episode, Dr. Hassaballa explains why. Article on physician subsidies: https://www.beckershospitalreview.com/finance/the-rising-cost-of-physician-subsidies-in-...

Both obesity and protein calorie malnutrition are major comorbid conditions (MCC), and they are frequent targets of post-discharge denials by payers. In this episode of Healthcare Musings, Dr. Hassaballa explains why it is so important that these diagnoses are not only documented, but why our plan to address these conditions must always be documented. GLIM Criteria: https://www.espen.org/education/glim

Acute hypoxic respiratory failure is diagnosed by one of these three criteria: PaO2 less than 60 mm Hg SpO2 less than 90% PaO2/FiO2 ratio < 300 That's it. Payers like to add all sorts of clinical criteria alongside this. This is totally wrong, and we should not let them get away with this when they dispute the presence of acute hypoxic respiratory failure during post-discharge DRG denials. During this episode, Dr. Hassaballa goes into the criteria of acute hypoxemic respiratory failure, so we ca...

Increasingly, insurance companies and third-party auditors are denying sepsis claims and DRGs based on the “Sepsis-3” article published almost 10 years ago. Specifically, they contend that if there is no SOFA score of 2 or greater there is no sepsis. Not so fast. The article never said that, and this is crucial when fighting sepsis denials. On this episode of the podcast, Dr. Hassaballa discusses this crucial fact to help hospitals and other providers fight these ever increasing sepsis denials. ...

Metabolic encephalopathy is a state of global cerebral dysfunction caused by systemic metabolic or toxic disturbances. Its presence raises the severity of illness of those patients afflicted with it, and it is a frequent denial target of payers. It is essential that clinicians document this condition in the record when it is present. In this episode, Dr. Hassaballa discusses this diagnosis and provides essential tips on how to properly document this condition.

There are two competing definitions of sepsis, called "Sepsis-2" and "Sepsis-3." They are vastly different, and it is causing enormous confusion with respect to diagnosing and coding for sepsis. I assembled a panel of experts to discuss the proper coding of sepsis. Does a UTI with fever and tachycardia really constitute sepsis? Does CMS mandate a specific definition of sepsis? What about SOFA scores? We delve into all of this and more. The panel for this episode is: Dr. Erin Boyd Dr. Ronald Hirs...

There is a growing battle between payers and providers, each using AI to get the most money. Are doctors and hospitals using these tools inappropriately? Articles: AI by Doctors: https://www.statnews.com/2025/08/20/ai-scribe-use-doctors-health-insurance-bills-may-rise/ AI by Insurers: https://www.statnews.com/2025/10/31/health-insurer-ai-fights-hospital-ai-coding-billing/

If an insurance payer denies a claim, and we write an appeal. The very least the payer must do is write a letter in response.

CMS unveiled the WISeR Model, a pilot of prior authorization for traditional Medicare beneficiaries. I have mixed feelings about it. NYT Article: https://www.nytimes.com/2025/08/28/health/medicare-prior-approval-health-care.html?smid=nytcore-ios-share&referringSource=articleShare CMS Press Release: https://www.cms.gov/priorities/innovation/innovation-models/wiser

Many payers state that a 2016 Coding Clinics article allows them to deny sepsis DRGs. This is not true, and Dr. Hassaballa goes into the article and what is specifically says about sepsis. And, he issues an unequivocal condemnation of the murder of Brian Thompson.

Insurance companies will use obscure “Coding Clinics” articles to deny various DRGs. I asked appeal expert Dr. Vivek Tirmal of Sound Advisory Services all about this.

As we conclude Sepsis Awareness Month, Dr. Hassaballa discusses how the definition of sepsis changes depending on which insurance company the patient uses.

In this latest episode in the series, "From the Appeals Desk," Dr. Hassaballa discusses acute respiratory failure and how to protect yourself and mitigate against denials of this diagnosis by insurance companies. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit healthcaremusings.substack.com

In this episode, Dr. Hassaballa discusses the most frustrating denial he deals with: the "30 Day Readmission" denial. It is purported to be similar to that by CMS, but this is totally false. Reference: https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-readmissions-reduction-program-hrrp This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit healthcaremusings.substack.com

Starting in 2024, Medicare Advantage plans must follow the Two-Midnight Rule. So, it behooves all clinicians to know that this rule is and document appropriately against it. Reference: https://www.beckerspayer.com/policy-updates/the-2-midnight-rule-and-medicare-advantage-6-things-to-know.html#:~:text=Under%20the%20final%20rule%2C%20an,necessary%20(case%2Dby%2Dcase This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit healthcarem...

It would be a travesty and a shame to have your documentation belie the truly great clinician you are. So it's high to focus on the assessment and plan, so we can really show the world the wonderful work we're doing on a daily basis. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit healthcaremusings.substack.com

In this episode, Dr. Hassaballa discusses medical necessity denials: what they are and how to deal with them. Resources: Interqual: https://www.changehealthcare.com/clinical-decision-support/interqual MCG: https://www.mcg.com/client-resources/news-item/mcg-27th-edition-care-guidelines/ This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit healthcaremusings.substack.com

Insurance company denials are terribly frustrating. There are a number of causes, and in this series, we will explore the types of denials and what we can do to mitigate them. Resources: "From the Appeals Desk": https://healthcaremusings.substack.com/t/from-the-appeals-desk Association for Healthcare Appeals and Denial Management (AHDAM): https://www.ahdam.org/ This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit healthcaremusi...